Mass Human Chemical Decontamination
Office of the Assistant Secretary for Preparedness & Response (ASPR)
U.S. Department of Health & Human Services (HHS)
Office of Health Affairs
U.S. Department of Homeland Security
March 2012
Mass Human Chemical Decontamination Working Group
OUTLINE
• Background
• Scope & Framework
• Foundational Work
• Developing National Guidance
Mass Human Chemical Decontamination Working Group
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Mass Human Chemical Decontamination
Working Group
Executive Office of the President
National Science & Technology Council
Committee on Homeland & National Security
Subcommittee on CBRNE Standards
Co-Chairs:
Department of Health and Human Services (HHS)
Assistant Secretary for Preparedness & Response (ASPR)
Sue Cibulsky, PhD
Chemical Science Branch Chief
Medical Countermeasure Strategy & Requirements Division
Office of Policy & Planning
Department of Homeland Security (DHS)
Office of Health Affairs (OHA)
Formerly: Mark Kirk, MD
Currently:
Joselito Ignacio, MA, MPH, CIH, CSP, REHS
CAPT, USPHS
Director, Chemical Defense Program
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MANDATE
Directed by Homeland Security Presidential Directive (HSPD)-22 and
White House National Security Staff through the Domestic Chemical
Preparedness and Response Sub-Interagency Policy Committee to
“support the development of State and local plans and protocols for
the decontamination of persons.”
• Create and publish evidence based principles and best practices:
National Guidance
– Intended for the local first responder/first receiver communities
– Facilitate their ability to implement a plan and execute mass
decontamination in a high consequence chemical event
• Review literature and summarize current evidence
• Identify and prioritize research needs: research roadmap
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MEMBERSHIP
Subject Matter Experts
US Agencies
First Responders
First Receivers
Military
Academia
Government
Public Health
Scientific Research
Health Care
Toxicology
Local Emergency Managers
CDC/NCEH/ATSDR
CDC/NIOSH
DHS/OHA
DHS/S&T
DHS/Plum Island
DoD/CBIRF
DoD/ECBC/USAMRICD
DoD/US Army CBRN School
DoD/OSD Policy
EPA
HHS/ASPR
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SCOPE AND FRAMEWORK
Mass Human Chemical Decontamination Working Group
SCOPE
Limited to:
• HUMAN decontamination in a mass casualty incident
• From accidental or intentional CHEMICAL contamination
• EXTERNAL contamination
Chemical agents addressed:
• Toxic Industrial Chemicals (TICs) & Toxic Industrial Materials (TIMs)
• Chemical Warfare Agents (CWAs)
Although radiological materials and biological agents are important and share some
basic similarities, they do not fall under the purview of this working group. Only
human exposures that potentially need medical care will be addressed.
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FRAMEWORK
Holistic Point of View (System of systems)
• Looking at the role of
decontamination (decisionmaking, procedural processes,
human factors) within the
complete response system
• Examining the
interdependencies within the
entire community response
Emergency
Management
First
Receivers
First
Responders
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Intel / LE
Public Health
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PHILOSOPHY
Decontamination is a medical countermeasure
• Decontamination is a first aid procedure
– Reduces amount of agent absorbed
– Reduces symptom severity
– Reduces need for antidotes and medical support
• Decontamination permits faster access to medical care
– Providers will not be hindered by PPE
– Supportive medical devices can be used without being contaminated and
possibly damaging equipment
• Decontamination reduces the risk of secondary contamination of
responders, equipment, infrastructure
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Unique aspects of workgroup
efforts
• Evidence based recommendations
• Scope: response of entire community/system
• Asking impactful questions
– Focused on operational questions
– Asking most critical question: not “how do we perform decon?” but
“why and when do we perform decon?”
• Developing a long term strategy
– Attempting to get buy-in and change culture
– Incorporate into training curriculum
– Planned periodic updates to incorporate newest research findings and
make recommendations for change
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FOUNDATIONAL WORK
Mass Human Chemical Decontamination Working Group
DEFINE THE PROBLEM
• Three main categories that establish logical response
timeline:
Decision-making
and Risk
Assessment
Process and
Procedure
Evaluation of
Results
• Two main areas:
– Individual Decontamination
– Mass Casualty Decontamination
• Six Core Questions
– Operational relevance: questions likely to have greatest
impact on mounting an effective response
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SIX CORE QUESTIONS
Individual Decontamination
Decision making and risk assessment
What criteria are available to decide if the patient needs
decontamination or not?
Process and Procedure
What is the optimized procedure for definitive decontamination for a
multi-peril scenario of unknown agent and unknown exposure?
Evaluation of results
What is the metric for determining effective decontamination?
Mass Patient Decontamination
Decision making and risk assessment
What is the best evidence-based method for assessment and triage
of victims (both at the scene and at hospitals) to prioritize
decontamination and medical treatment?
Process and Procedure
Where and when should decontamination take place?
Evaluation of results
Risk Communication - What evidence-based, best practice crisis
communication techniques can be best applied to a mass casualty
chemical incident to promote patient compliance and safety during
decontamination?
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LITERATURE REVIEW
• Using the six core questions as a guide:
– Conducted an extensive review of the literature
– Assessed the type and quality of evidence
– Created a comprehensive bibliography
– Invited wider audience to review at 2010 symposium
• Significant gaps exist in the available evidence
• Currently developing a matrix of research questions to
address these gaps
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IDENTIFIED GAPS
• Insufficient data available to suggest the best criteria
to determine need for decontamination
• Efficacy of clothing removal has not been
quantitatively established
• Optimal parameters for water-based
decontamination have not been determined (e.g.,
pressure, temp, duration)
• No definitive studies comparing efficacy of wateronly vs. soap-and-water
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IDENTIFIED GAPS
• No validated metrics for assessing the effectiveness
of decontamination
• Little understanding of the types of information and
other support that could be provided to patients to
promote safety and compliance with
decontamination procedures
• Few studies to examine potential harmful effects of
decontamination (physiological and psychological)
• Little evidence to suggest optimal mechanisms for
disseminating information to the community in a
mass casualty incident
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GUIDANCE CROSSWALK
• Using core questions as a guide, identified 46 topics
• What do other guidance documents say on these
topics?
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KEEPING THE END-USER IN MIND:
PRACTITIONER INTERVIEWS
• Interaction design method
– Providing end-user input in product
development
– One-on-one, scenario based interviews
– Developed and analyzed using strategic
choices
• What did we gain from this work?
– A better understanding of current planning and practices
– Identifying goals, priorities, and concerns of the individual
responders and receivers
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DEVELOPING NATIONAL GUIDANCE
Mass Human Chemical Decontamination Working Group
SCOPE
• Assist in decision-making from
a planning perspective but will
not outline specific procedures.
• Audience: First Responders AND First Receivers at
the planning, training, and Incident Commander
levels
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HIGH LEVEL PRINCIPLES
• Evidence-based where there is evidence
– When there is no evidence, based on current practices,
SME consensus, and previous experiences (anecdotal and
case history reports, etc.)
• Promote the Risk-based Response (RBR) approach
• Fit within the NIMS/ICS framework
• Do the best for the most, with available resources
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FORMAT
• 2-part guidance document:
– Part I: quick-reference guide
• Functional Area
• Guidance Statement
– Includes additional considerations to this recommendation (if any)
• Level of Certainty
– Based on literature review, current guidance crosswalk, practitioner
interviews and expert consensus
– Part II: includes supporting documentation
• Supplies the rationale behind the recommendation
• Includes references to the published literature, when applicable
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EXAMPLE
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STAKEHOLDER ENGAGEMENT
Guidance Statements revised based on 2012 symposium
Submit to Key Partners for review and comment – March 23
Deliver full draft Guidance Document to Subcommittee on CBRNE
Standards and Chem sub-IPC/National Security Staff – June
Submit to Committee on Homeland and National Security and Domestic
Resilience Group; HHS and DHS Exec Sec Departmental clearances - July
Federal interagency/state/local coordination
Public comment period – July/August
Final publication and implementation plan
Plan for future revisions
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KEY PARTNERS (Partial List)
•
•
•
•
•
•
Interagency Board
National Fire Protection Association
International Association of Fire Chiefs
National Association of EMS Physicians
National Association of EMS Educators
National Association of State EMS
Directors
• Joint Commission on Accreditation of
Healthcare Organizations
• American College of Emergency
Physicians
• American College of Medical
Toxicology
• Emergency Nurses Association
• National Association of Emergency
Medical Technicians
• National Registry of Emergency
Medical Technicians
• American Hospital Association
• American Nurses Association
• American Medical Association
• National Emergency Management
Association
• American College of Occupational
and Environmental Medicine
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LONG-TERM OBJECTIVES
• Recommended evidence-based principles and best practices
• A systems engineering approach to delivering an optimized response in a
mass casualty incident
• Decision support tools for triage and altered standards of care
• Metrics for measuring individual and community competencies
• National training standards and professional education curriculum derived
from guidance
• Grants directed at facilitating each community’s ability to achieve
competencies in delivering mass decontamination
• Equipment that meets standards that support optimized response or
facilitate systems approach to delivering optimized response more
efficiently
• Research program to continually refine the evidence in support of
delivering an effective, efficient and easily achievable decontamination
response
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REQUEST FOR THE AUDIENCE
• Contribute edits and comments on the draft
guidance document
– Work through identified Point of Contact for your
organization
Mass Human Chemical Decontamination Working Group
CONTACT INFORMATION
Sue Cibulsky – susan.cibulsky@hhs.gov
Joselito Ignacio - Joselito.Ignacio@HQ.DHS.GOV
Adam Leary – adam.leary@hhs.gov
Hillary Sadoff - hillary.sadoff@associates.hq.dhs.gov
Mass Human Chemical Decontamination Working Group
EXTRA SLIDES
Mass Human Chemical Decontamination Working Group
Guidance Statement 1.1
The decision to decontaminate should take into account a
combination of information, including (but not limited to):
– Patients displaying signs and symptoms of exposure
– Visual evidence of contamination on the patient’s skin or
clothing
– Proximity of patient to the location of the release
– Contamination is detected on patient using appropriate
detection technology
– The chemical identity (if known), characteristics, and behavior
– If patient requests or demands decon, even if contamination
is unlikely
Functional Area #1: Determine Need for Decontamination
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Guidance Statement 1.1
Considerations:
– Signs and symptoms of chemical exposure may present as one or more
recognized toxidromes or as single symptoms
– Some signs and symptoms may not reflect actual chemical exposure, but
manifest as a result of fear, anxiety, or panic due to presence at the
traumatic incident itself
– Environmental detectors are available for many CWAs, TICs and TIMs but
are not readily adaptable to or available for the detection of
contamination on patients likely to be encountered in a hazardous
materials incident
Functional Area #1: Determine Need for Decontamination
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Guidance Statement 1.2
Decontamination should be performed if the potential
contamination on patients requiring transport to, or care in, a
medical facility poses a reasonable risk of exposure to first
responders/receivers or contamination of critical infrastructure.
Considerations:
– As a sole criterion, prevention of secondary contamination alone may not
justify patient decontamination; the following patients are unlikely to
pose a significant risk to responders and receivers:
•
•
•
Have neither signs nor symptoms
Have no visible contamination on skin or clothing, AND
Have a history that makes exposure unlikely (i.e., not near the location of
release)
Functional Area #1: Determine Need for Decontamination
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Guidance Statement 1.3
If the likelihood of adverse consequences of immediate or
thorough water-based decontamination itself outweighs the likely
health outcome gains of decontaminating patients, then
decontamination should be performed using alternative
procedures.
Considerations:
– Patient decontamination is not without risk; appropriate measures
should be taken to mitigate these risks and reduce the negative impact
on patients
– Reference Guidance Statement 2.10 for alternative procedures
– Adverse consequences might include contraindications due to weather
(freezing temperatures, hypothermia) or chemical reactivity (waterreactive chemicals or metals, e.g., lithium or sodium metal)
Functional Area #1: Determine Need for Decontamination
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Guidance Statement 2.1
A risk-based approach should be employed by the responding or
receiving organization to determine the appropriate response level
(including PPE, medical interventions, decontamination).
Considerations:
– An appropriately trained person (e.g., see Hazardous Waste Operations
and Emergency Response (HAZWOPER) standards) in appropriate PPE
should perform the assessment
– PPE determination should be made based on applicable guidance,
regulations, subject matter expertise and manufacturer’s specifications
(e.g., OSHA, NIOSH, NFPA, etc.)
Functional Area #2: Optimized Technical Parameters for the Process
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Guidance Statement 2.2
Patient decontamination should be performed using a tiered approach.
The level and nature of decontamination is determined by the level and
nature of contamination, as estimated through a risk-based response, as
well as available resources. The tiered decontamination response is
flexible and adaptable to various types of incidents.
Three tiers* are recommended:
– Self-care: actions that patients can perform for themselves, including distancing
themselves from the site of release, removing clothing, and wiping visible
contamination from skin and clothing
– Immediate: likely to be performed by or with the assistance of first responders or
first receivers in order to achieve a gross or hasty reduction in contamination as
soon as possible, e.g., water decon with fire hoses at the scene
– Thorough: likely to be performed under the guidance of first responders or first
receivers in order to achieve a level of contamination reduction that is as low as
reasonably achievable, e.g., water- or soap and water-based shower
*Tier names still under consideration
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Guidance Statement 2.3
Consider clothing removal for patients who have been visibly
contaminated or who are suspected of having been
contaminated. Efforts should be made to collect and account for
clothing and personal items removed for patient
decontamination.
Considerations:
– If clothing removal is to be conducted outside, be mindful of
environmental risks and, if applicable, ensure warming or cooling
methods are available (e.g., warming tent, indoor location, shaded area)
– Some patients may require assistance in removing clothing
– Ensure proper levels of modesty (e.g., separate lines for males and
females and cover from bystanders)
Functional Area #2: Optimized Technical Parameters for the Process
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Guidance Statement 2.3
Considerations, continued:
– Clothing and personal items should be handled in such a manner to
address the following priorities
1.
2.
3.
Protect the health and safety of patients, responders and receivers
Evidence collection for law enforcement
Logistical capabilities
– Patients should be allowed to maintain identification (e.g., ID card,
driver’s license) that can be processed through decontamination without
being destroyed or retaining contamination
– If the incident is a criminal or terrorist activity, clothing and personal
items may become evidence; law enforcement should be incorporated
into response planning to develop standard operating procedures for
collecting contaminated material and ensuring chain of custody
Functional Area #2: Optimized Technical Parameters for the Process
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Guidance Statement 4.1
Prioritize patients for decontamination by estimating relative risk
and grouping patients into imminent and delayed decontamination
groups. Risk assessment should take into consideration the
following criteria (and others as appropriate):
–
–
–
–
–
Need for immediate lifesaving care or antidotal therapy
Visual evidence of contamination on patient’s skin or clothing
Patients displaying signs and symptoms of exposure
Proximity of patient to the location of release
Contamination detected on patient using appropriate
detection technology
Functional Area #4: Patient Prioritization for Decontamination
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Guidance Statement 4.1
Considerations:
– Priority should begin with those patients who require decontamination in
order to receive immediate, lifesaving care or antidotal therapy
– Children should be prioritized before adults within the same
decontamination priority group
– Age, pregnancy and chronic medical conditions should also be considered
when estimating relative risk and prioritizing patients for decontamination
– In a mass casualty chemical incident, patients needing decontamination
most urgently may not be the first to present; ambulatory patients may
reach first responders or first responders more quickly than nonambulatory patients
– Self-reporting patients arriving at a Health Care Facility should also be
prioritized according to these criteria
Functional Area #4: Patient Prioritization for Decontamination
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Guidance Statement 5.1
Attempt to immediately decrease ongoing exposure by removing
ALL patients out of the danger area and provide an area of refuge.
Considerations:
– First responders should not enter the danger zone without appropriate
PPE and training
– Determination for subsequent need and level of decontamination may
be decided based on criteria in Guidance Statements 1.1, 2.1, 2.10 and
4.1
Functional Area #5: System-wide coordination of patient decontamination
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